The Three Worksheet Pages

This is a description of the information on the PDF workpages.

You can ask an ACA Navigator for assisstance. For toll‑free calls and online chat: https://www.healthcare.gov/contact-us/ .

 

FIRST WORKSHEET

Basic Health Plan Questions

  1. Is this an HMO, PPO, EPO, POS, or HDHP plan?
  2. Do they have a large network of doctors and medical centers?
  3. Can we get to their offices and medical centers easily?
  4. Can the providers share my family’s records electronically?
  5. Does the plan cover all the special treatments my family needs?
  6. Does it cover the prescriptions and brand names we are taking?
  7. Does the insurer limit how much they will pay for prescriptions or any other services?
  8. Will I be covered if I need treatment while in another city? State? Country?
  9. Is there a telephone hotline I can call at any time to ask about symptoms or problems that might require immediate attention?
  10. Are copays listed as fixed dollar amounts or percentages?
  11. If percentages, what are appointments or prescriptions likely to cost?
  12. Does the Summary of Benefits and Coverage have complicated exceptions and things I can’t understand? Will the insurer explain them?
  13. Can we enroll in more than one plan?

End of health-plan questions. You can return to first question or continue to the next worksheet.

Return to first question.

 

SECOND WORKSHEET (general information and instructions for using the third worksheet)

 

What to Look for in a Plan

The page explains of some of the things you should know about health plans.

DRUG FORMULARIES

Plans often list drugs in three or more price tiers.

1. Generic drugs are less expensive even though they are identical to the original drug (for example, the generic alendronate and the brand-name Fosamax).

2. Discounted brand-name drugs (or brand formulary) are drugs the insurer can buy (and sell) at a lower price than a pharmacy can.

3. Brand-name drugs (or non-formulary) that are not part of the formulary may cost as much as they would at a pharmacy.

BUYING MORE THAN ONE PLAN

If some members of the household require more expensive treatments or drugs, you may be able to put them in a Gold or Platinum plan, and everyone else in a plan with lower premiums. Or you might have a separate plan for a child under 26 who is currently living in another county or state. The tax credit would be divided between the plans.

COPAYS

These are not included in your deductible, but ACA plans do count them as part of your out-of-pocket maximum. Other plans may not.

The ACA (and many other sources) define copays as fixed amounts ($15 for drug, say), but some plans list copays as percentages of whatever a charge may be (20% of the drug cost) or as coinsurance after deductible (which seems to mean that they treat copays as coinsurance). Ask the insurer.

OUT-OF POCKET MAXIMUMS

These cannot be higher than the ACA limit, but some plans do have lower ones. Your deductible is part of your out-of-pocket maximum.

OUT-OF-STATE COVERAGE

Some insurers have facilities in other states and some may cover you in other countries. See Other Covered Services in the Summaries of Benefits and Coverage. If you need to be covered, you should be able to buy travel insurance through a travel agent.

CHOOSING AN INSURER

Insurance companies

Marketplace plans meet ACA standards, but in the past insurers were largely unregulated, and some of them did things that are no longer allowed. To learn about reputations, see their Wikipedia page’s section on legal issues (it may have a different name). Also do searches to find out if they often lay off large numbers of providers.

Wikipedia list of U.S. insurers

insurance plan rankings by state

Hospitals

Ratings by magazines and nonprofit groups are usually based on statistics and visits to the facilities.

Patients’reviews usually focus on the food and rooms.

Hospitals that require the use of the World Health Organization Surgical Checklist have more successful surgeries.

Medicare’s Hospital Comparison page

Consumer Reports (subscription required)

Hospitals that use the World Health Organization Surgical Checklist

Insurance Co-ops

Many states offer plans from these non-profit insurers. They can charge less and provide good service because they don’t spend huge amounts on monumental buildings and large executive salaries.

DEDUCTIBLES

Some plans require separate deductibles for each family member. They may also require separate deductibles for pharmaceuticals.

You can find this information in the Summaries of Benefits and Coverage.

The subsidies are included in the premium prices in these examples. The premiums plus the out-of-pocket maximum are the most your health insurance costs could come to during the plan year.

The next two sections list things you should take note of so you can compare plans. Each has fictional examples to give you an idea of what is being asked for.

The first is for a plan for one person.

  1. Name and type of plan: Super Bronze Advantageous, PPO.
  2. Premium cost and out-of-pocket maximum combined: 261 dollars a month times 12 equals 3,132 plus 6,350 comes to a possible maximum cost to the enrollee of 9,482 dollars.
  3. Amount of Deductible: $2,600.
  4. Typical copay prices: doctor visit 20%, drugs: an undisclosed percentage, ER $500.
  5. Are services I may need covered? Bariatric surgery, yes.
  6. Are services I may need excluded? Weight-loss program and adult routine eye care, yes.
  7. Limits that might affect me: rehabilitation and habilitation: no more than 30 visits per benefit period (usually a year).

The second is a plan for a family of three.

  1. Name and type of plan: Silver Beauty Super Saver. Type: HMO.
  2. Premium cost and out-of-pocket maximum combined: 652 dollars a month times 12 equals 7,824 plus 12,700, which could come to as much as 20,524 dollars in a year.
  3. Amount of Deductible: $4,500 and $950 for drugs.
  4. Typical copay prices: doctor visit $30, Emergency Room $650.
  5. Are services we need covered? Medically necessary cosmetic surgery, yes.
  6. Are services we need excluded? No, none.
  7. What limits might affect us? None.

THIRD WORKSHEET

Here are the same headings without the example answers:

  1. Name and type of plan
  2. Premium cost and out-of-pocket maximum combined
  3. Amount of Deductible
  4. Typical copay prices
  5. Are services we need covered?
  6. Are services we need excluded?
  7. Limits that might affect us

Return to the start of the third worksheet questions

 

Final URLs

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